Family Practice Vol. 18, No. 6, 581-585
© Oxford University Press 2001
Original Paper |
GPs' attitudes to minor ailments
School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester M13 9PL and
a Division of Primary Healthcare, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.
Dr Caroline Morris, Drug Usage and Pharmacy Practice Group, School of Pharmacy and Pharmaceutical Sciences, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
Morris CJ, Cantrill JA and Weiss MC. GP' attitudes to minor ailments. Family Practice 2001; 18: 581–585.
Received 1 March 2001; Accepted 9 July 2001.
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Abstract |
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Background. It is generally considered that a significant proportion of ‘inappropriate’ demand for GP services is generated by consultations for minor ailments. How GPs manage minor ailments is likely to affect how patients perceive and handle similar illnesses in the future. Whilst this potentially has significant implications for general practice workload, research investigating GP' attitudes towards minor ailments and their management is sparse.
Objective. Our aim was to describe GP' experiences and perceptions of minor ailment consultations and their attitudes towards minor ailment management.
Methods. A questionnaire survey was conducted in 1999, derived from a series of 20 qualitative interviews with practising GPs. The survey was sent to one GP randomly selected from each practice (n = 759) in eight English health authorities. Attitudinal statements were analysed using factor analysis.
Results. Four hundred and fourteen GPs (54.5%) completed and returned the questionnaire. Respondents were consulted regularly about minor illness or symptoms, with almost all (95.6%) having experienced a minor ailment consultation in the previous week. Factor analysis suggested four issues to be of importance in determining GP' attitudes to minor ailment management. These were attitudes towards pharmacists, attitudes towards patient empowerment, frustration with minor ailment consultations and attitudes towards caution/risk.
Conclusion. Although GPs are clearly frustrated by the level of minor ailment consultations, this study suggests that there may be complex factors which influence their attitudes. For the optimal management of minor ailments, inter-professional relationships potentially are of great importance. With increasing patient demand, it is essential that finite health care resources are accessible, appropriate and used in an optimal way.
Keywords. General practice, GP' attitudes, minor ailments.
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Introduction |
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In recent years, patient' expectations of health care have escalated, with a resultant increased demand on GP services.1 It is generally considered that a significant proportion of ‘inappropriate’ demand is generated by consultations for minor ailments. There is, however, limited research investigating GP' attitudes towards minor ailment consultations.
In 1995, research commissioned by the Proprietary Association of Great Britain on attitudes to over-the-counter (OTC) medicines showed that 28% of 200 GPs interviewed felt that they were spending more than 70% of their time on minor ailments.2 A similar study conducted a year later identified that a sample of 200 GPs felt that 
39% of their time was spent dealing with minor ailments that did not need their attention.3 However, academic research has tended to focus on trivial, unnecessary or inappropriate consultations rather than minor ailments per se. While such consultations have been identified recently as a considerable source of frustration for some GPs,4 much of the work is dated,5–7 and hence its relevance to general practice today is questionable. In recent years, there have been substantial, rapid changes in the organization of both primary care and society in general. There has been a shift towards patient empowerment and increasing consumerism. As a way of simultaneously increasing access to care and stemming demand on GP time, some practices have used nurses to triage and manage acute illness. The Government response has been the expansion of National Health Service (NHS) Direct and the introduction of NHS Primary Care walk-in centres.
The way in which GPs manage patients consulting with minor ailments is likely to affect how that illness is perceived and subsequently handled by the patient, thus having significant implications for general practice workload. The aim of this study was to describe GP' experiences and perceptions of minor ailment consultations and their attitudes towards minor ailment management.
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Methods |
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A national questionnaire survey of 759 GPs was undertaken. One GP was selected randomly from each practice in eight randomly selected English health authorities. A series of attitudinal statements were presented in the survey and GPs were asked to specify, on a Likert scale ranging from strongly agree to strongly disagree, which rating best described their view towards each statement. The statements were developed from 20 qualitative interviews conducted with a diverse sample of practising GPs by CJM. The statements encompassed three a priori groupings (see Box 1
). GPs were also asked about the frequency with which they were consulted about minor illness or symptoms, whether they had experienced such a consultation in the previous week and, where appropriate, for brief details of the illness or symptoms precipitating this most recent minor ailment consultation. Two GPs provided constructive comment on an early draft of the questionnaire and it was piloted on 30 GPs randomly selected from the main study sampling frame. The first mailing was dispatched in January 1999 with two postal reminders sent to non-responders at 3-weekly intervals. The attitudinal statements were analysed with SPSS for Windows v8.0 using factor analysis. This is a form of data reduction which enables exploration of the existence of any relationships underlying the original variables that can be summarized in a smaller set of constructs or dimensions.8 In this instance, it was used to assess the a priori groupings (Box 1). Factors were extracted using principal component analysis with varimax rotation and tested for internal reliability using Cronbach's alpha.
| Box 1 A priori groupingsa General attitudes towards minor ailment consultations (statement numbers 1, 2, 5, 6 and 7). Views on their own role and patient' responsibilities in the management of minor ailments (statement numbers 3, 4, 8, 11 and 12). Views on the role of pharmacists in minor ailment management (statement numbers 9, 10, 13 and 14).
a The precise wording of each statement is shown in Table 1
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Results |
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The final response rate was 58.9% (447/759). Of the questionnaires returned, 414 were suitable for analysis, giving an overall usable response rate of 54.5%. The usable response rate from individual health authorities ranged from 35.3 to 71.9%. Respondents had a mean age of 46 years (range 29–68) and worked in practices with a median of three partners (range 1–12). Male GPs were over-represented (72.5% versus 66.7%, chi-squared P < 0.01) and single-handed practices under-represented (23.4% versus 29.8%, chi-squared P < 0.01) when compared with national figures.9
Experiences of minor ailment consultations
The majority of respondents (356/413, 86.2%) identified that they were consulted about illnesses or symptoms that they considered to be minor either very often or often. Almost all respondents (394/412, 95.6%) had experienced a minor ailment consultation in the previous week. As data collection took place between January and March, it is unsurprising that approximately three-quarters related to upper respiratory tract symptoms.
Factor analysis
Responses to the attitudinal statements are shown in Table 1
. Three statements (numbers 2, 7 and 8) showed no substantial correlation with any other statement (all coefficients were <0.3) and thus were removed from the subsequent analysis.
A total of 11 factors were extracted. After an assessment of the eigenvalue of each factor, together with an inspection of the scree plot,8 four factors were retained. These four factors accounted for 64.6% of the variance. Factor loadings, which indicate the correlation between the original statements and the resulting factor,8 were determined for each statement within each of the four factors. For interpretation purposes, a cut-off point of ±0.5 was used. The percentage of variation explained by each factor in the four-factor solution and the factor loading for each statement within each group are shown in Table 2.
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The value of Cronbach's alpha was 0.66 or greater for factors 1–3, suggesting that the items correlated well within the factors. As factor 4 comprised one statement alone, it was inappropriate to conduct the test for this factor. The first factor accounted for almost 30% of the variance (Table 2
) and described attitudes towards pharmacists. The other factors described attitudes towards patient empowerment (factor 2), GP frustration with minor ailment consultations (factor 3) and attitudes towards cautious behaviour or risk (factor 4). These results confirm, to a limited extent, the a priori groupings which had been made (Box 1).
Attitudes towards pharmacists.
This factor directly supported one of the a priori groupings. All of the statements loading highly on factor 1 (statements 9, 10, 13 and 14) had been grouped previously to determine GP' views on the role of pharmacists in minor ailment management (Box 1). Many respondents were supportive of a role for the pharmacist, and this comment illustrates the belief of some GPs that the professions potentially had much to offer each other:
"I think there is still a long way to go in the doctor/ pharmacist relationship in general practice. If trust can be built up there is a lot of potential for mutual support."
Attitudes towards patient empowerment.
Although factor 2 (statements 6, 11 and 12) did not exactly support an a priori grouping, it was, in part, reflected by GP' views on their own role and patient' responsibilities in minor ailment management (Box 1). Statements 3, 4, 8, 11 and 12 were grouped initially within this theme. Statement 8 was eliminated due to poor correlation with all other statements, statement 3 was factor 4 and statement 4 was part of factor 3. As the statements comprising this factor show a willingness to let patients self-manage in the first instance, it could be termed a patient empowerment factor. However, whatever an individual GP's attitude may be to patient empowerment, some GPs identified external factors as influential. This comment elaborates this concern:
"The Government and media are encouraging people to be more and more dependent on health services, with taking less and less responsibility for themselves. People tolerate much less uncertainty than they used to so they come at an earlier stage in their illness."
Frustration with minor ailment consultations.
Factor 3 comprised statements 1, 4 and 5. Statements 1 and 5 were placed in the a priori grouping which reflected general attitudes towards minor ailment consultations. Statement 4 was grouped with others relating to GP' views on their own role and patient' responsibilities in minor ailment management (Box 1). However, when the statements loading highly on this factor are viewed as an entity, they represent GP frustration at patients consulting with minor ailments. This suggests that the a priori grouping of general attitudes to minor ailment consultations was too broad. Factor analysis has broken down some of the issues further. The source of this frustration was clearly expressed in a comment from one respondent:
"Minor illness consultations can be a break from more complex cases, but there can be a lot of frustration at spending in total a lot of time and feeling that there is then less available for those who ‘really need it’ or at it encroaching into our own time."
Attitudes towards cautious behaviour or risk.
The fourth factor should be interpreted somewhat cautiously. It may be considered slightly tenuous given the fact it comprised a single statement. Statement 3 was part of the a priori grouping of GP' views on their own role and patient' responsibilities in minor ailment management (Box 1). As this statement was the only one in the survey which specifically elicited attitudes towards cautious behaviour or risk, it suggests that this a priori grouping had also been too broad. In retrospect, more statements may have been merited to explore this particular GP characteristic identified by factor 4. A comment at the end of a questionnaire elaborates one GP's particular concern:
"‘Minor illnes' can only be defined in retrospect when a perceived self-limiting condition resolves."
Another GP explored the risks of spending too much time on minor ailments at the expense of a preventative medicine role:
"Is a doctor who has to spend his time prescribing for minor illness and therefore less time seeking outBP [blood pressure] & diabetes guilty of negligence??!"
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Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionReferences |
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Although the final response rate of 54.5% limits the generalizability of the results, it was considered acceptable given the acknowledged difficulties with recruiting GPs to research studies. The generalizability of these findings is limited further by the fact that the sample was not representative of all English GPs. Although careful attention was paid to the face and content validity during questionnaire development, other aspects of validity and reliability of the questionnaire were not formally investigated. Assessment of ‘test–re-test’ reliability would have shown whether GP' views were changeable or stable from day to day. However, we would anticipate that in light of the diverse nature of minor ailment caseload, their views would be subject to change.
Despite these limitations, this study is the first to explore specifically how GPs feel that minor ailments should be managed. While these GPs expressed frustration with their minor ailment workload, this study indicated that there may be complex factors influencing their view. Factor analysis suggested four issues to be of importance in determining GP' attitudes. These were attitudes towards pharmacists, attitudes towards patient empowerment, frustration with minor ailment consultations and attitudes towards caution/risk.
Many respondents expressed frustration at the level of their minor ailment workload. Although a minor ailment consultation is not necessarily synonymous with a trivial, unnecessary or inappropriate one, these findings would appear to support those from a study of GP ‘well-being’.4 Only 6% of a sample of 334 London GPs had never felt frustrated by the proportion of their workload for trivial, unnecessary or inappropriate problems. Furthermore, 46% identified that they were often frustrated by such consultations.
The dimension of attitude to risk is worthy of future research as this study was unable to deconstruct some potentially important issues. These included whether some GPs were inherently cautious individuals or whether, in an increasingly litigious society, such behaviour is for the benefit of patients or themselves. Further research could also help to unravel whether a degree of overlap exists between cautious behaviour and a possible desire to retain control over patients or, potentially, other health professionals.
It is notable that although the majority of the sample displayed favourable attitudes towards the pharmacist' role in minor ailments, only about half agreed that they would like actively to recommend that patients seek advice from a pharmacist. The fact that the lack of a personal relationship with a pharmacist appeared to influence their view (Table 1, statement 14) is an important issue. Inter-professional relationships are likely to become increasingly difficult as a result of demographic changes in community pharmacy. In recent years, there has been a shift towards increasing numbers of employee and locum pharmacists with decreasing numbers of independently owned pharmacies.10 Easier access to pharmacy services out of hours is a key Government proposal in the NHS plan;11 however, extended opening hours and the necessity for more than one pharmacist to cover the working day may hinder inter-professional relationships further.
How patients handle minor ailments, whether by self-management, utilization of a health professional other than the GP or a GP consultation, has a direct impact on escalating health care expenditure. With increasing patient demand, it is essential that finite health care resources are accessible, appropriate and used in an optimal way.
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Acknowledgments |
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We are grateful to all those GPs who contributed to this study by taking the time to complete the questionnaire.
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References |
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1 Gillam S, Pencheon D. Managing demand in general practice. Br Med J 1998; 316: 1895–1898.
2 Walker R. Attitudes to OTC medicines. In: Proprietary Association of Great Britain. OTC Directory 1996/1997. London: PAGB, 1996.
3 Anon. 39 per cent of GP' time lost on minor ailments. Pharm J 1997; 258: 494.
4 Grieve S. Measuring morale—does practice area deprivation affect doctor' well-being? Br J Gen Pract 1997; 47: 547–552.[Medline]
5 Cartwright A. Patients and Their Doctors. A Study of General Practice. London: Routledge and Kegan Paul, 1967.
6 Dunnell K, Cartwright A. Medicine Takers, Prescribers and Hoarders. London: Routledge and Kegan Paul, 1972.
7 Cartwright A, Anderson R. General Practice Revisited. A Second Study of Patients and Their Doctors. Cambridge: Tavistock Publications, 1981.
8 Hair JF, Anderson RE, Tatham RL, Black WC. Multivariate Data Analysis with Readings, 3rd edn. New York: Macmillan Publishing Company, 1992.
9 Department of Health. Statistics for General Medical Practitioners in England: 1988–1998. London: Department of Health, 1999.
10 Hassell K. The impact of social change on professions—gender and pharmacy in the UK: an agenda for action. Int J Pharm Pract 2000; 8: 1–9.
11 Department of Health. Pharmacy in the Future—Implementing the NHS Plan. London: Department of Health, 2000.
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